Pocket Guide to Quality Improvement in Healthcare

This text will act as a quick quality improvement reference and resource for every role within the healthcare system including physicians, nurses, support staff, security, fellows, residents, therapists, managers, directors, chiefs, and board members. It aims to provide a broad overview of quality improvement concepts and how they can be immediately pertinent to one's role. The editors have used a tiered approach, outlining what each role needs to lead a QI project, participate as a team member, set goals and identify resources to drive improvements in care delivery.  Each section of the book targets a specific group within the healthcare organization. Pocket Guide to Quality Improvement in Healthcare will guide the individual, as well as the organization to fully engage all staff in QI, creating a safety culture, and ultimately strengthening care delivery.

• Language: English
• Publisher: Springer
• Release date: May 21, 2021
• ISBN: 9783030707804

Book preview

© Springer Nature Switzerland AG 2021

R. Roberts-Turner, R. K. Shah (eds.)Pocket Guide to Quality Improvement in Healthcare https://doi.org/10.1007/978-3-030-70780-4_1

1. An Introduction to Quality Improvement: What We Need to Know in Healthcare

Reneè Roberts-Turner¹   and Rahul K. Shah²  

(1)

Nursing Science, Professional Practice, Quality and Magnet® Program Director, Children’s National Hospital, Washington, DC, USA

(2)

Chief Quality and Safety Officer, Children’s National Hospital, Washington, DC, USA

Reneè Roberts-Turner (Corresponding author)

Email: [e-mail]

Rahul K. Shah

Email: [e-mail]

Keyword

Model for improvementPDSA cyclesQuality improvement (QI) processHigh-reliability organizations (HROs)DataPatient care

This book is for you! Healthcare is one of the most complex endeavors where there is only one successful outcome: optimal care for the patient. All efforts and strategies in healthcare should be focused on solely one thing: the patient. How do we ensure the delivery of the highest level of quality in a safe manner? It is not easy.

A patient may encounter only a nurse, a therapist, and a provider (all referred to as the sharp end of care delivery ) and not necessarily interact with the environmental services team, the finance team, the dietary team, etc. (sometimes referred to as the blunt end of care delivery ); however, for a successful outcome with the highest level of care delivery in the safest manner, all parts of the healthcare team have to be working together all the time. It is not easy.

We (Reneè and Rahul) are both part of the sharp end of care delivery as a nurse and surgeon, respectively. We are both part of the blunt end of care delivery as part of the administrative leadership of Children’s National Hospital, a tertiary-care freestanding children’s hospital in Washington, District of Columbia, in the United States. Our hospital has been serving patients for 150 years! The reader can imagine the tremendous change that has occurred during that time in care delivery. One thing has remained solid and constant: we serve the patients.

To best serve our patients, we have to continually look for innovative approaches to drive care delivery, within the framework of safe and quality care. We do this by learning from other industries, other hospitals, and the overall academic literature. We take known strategies and implement these to improve care. In doing so, we quickly realized that we are missing an opportunity to educate colleagues, support staff, board members, and, ultimately, patients. There is not a definitive primer for all those involved in healthcare to be on the same page. How can we expect a patient and their family to understand PDSA cycles and how the model for improvement is being utilized to ensure she receives the highest level and safest care? How can we expect a board member, who has the fiduciary responsibility to serve the community’s interests and ensure their hospital’s success and to learn about the safety and quality part of the organization when they must be focused on the financials, strategy, and the hospital’s role in the community? This book fills this gap. This book provides all different parts of the healthcare system a primer on safety and quality so that we can speak a common language and jointly drive safety and quality care for our patients.

The objectives of this book are to help all healthcare professionals understand the basic principles of quality improvement by walking the reader through the step-by-step quality improvement process, as well as through the various domains that comprise the parts of the quality and safety engine. We hope to be able to guide individuals and organizations to fully engage staff in quality improvement . This knowledge for all healthcare staff is necessary, as healthcare systems must continue to strengthen and fortify care delivery and the desired associated outcomes. We aim to educate individuals that want to know more about quality improvement and how QI processes and data impact the care provided to patients and families. To achieve this goal, we lay out the foundations of healthcare quality and describe how these methodologies can be applied to the everyday work habits of the healthcare professional in their settings. In addition, we provide patient and family perspectives and relevant quality improvement information for decision making entities such as management and guidance for governance from hospital boards.

A framework is necessary to understand healthcare in this era and, subsequently, how to utilize quality improvement tools and techniques. The Donabedian triad is a commonly used improvement framework and the one we both employ all the time in our organization! The triad is structure, process, and outcomes.

We focus and perseverate on the structure – do we have the right teams, are the correct individuals on the team, does the team meet frequently enough, does the team have a clear reporting hierarchy, etc.

Then we ensure the processes are in place – are there audits, do we track metrics, how do we respond when data goes the wrong direction, etc. By spending over 95% of our team’s time and effort on structure and processes, outcomes are expected to follow.

A fallacy in quality improvement is to go right for the outcome without consideration of the structure and processes that need to be in place for the outcome to be resulted and then sustained.

The ultimate aim is to create a high-reliability organization . High-reliability organizations (HROs) "operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents [1]." Achieving the outcomes in the goal would be the holy grail of care delivery; as a patient, I want this and expect it. As a healthcare system, we owe it to our patients and community to strive for reliability. Weick and Sutcliffe’s easy-to-read book [1] has become mantra in healthcare organizations that strive to deliver optimal and safe care using their high-reliability principles. Behaviors associated with high-reliability organizations include preoccupation with failure, sensitivity to operations, reluctance to simplify interpretations, deference to expertise, and commitment to resilience [1]. These are absolutely nonnegotiable tenets in a healthcare setting and deserve highlighting. Preoccupation with failure involves a culture that encourages the identification of work processes that raise concern for potential failure [1]. Sensitivity to operations requires an awareness of how processes and systems affect the organization through early recognition of threats to the organization, which involves attentiveness to small changes in daily work [1]. Reluctance to simplify requires identification of the slight differences between threats through in-depth scrutiny, which involves using various methods of exploration, designed to identify the real source of the problem [1]. Deference to expertise requires that decision making is directed towards the person with the most knowledge and expertise to handle the situation at hand, usually not the top of the organization [1]. Commitment to resilience requires that everyone is confident regarding the organization and that it will bounce back from any events that inevitably will occur [1].

Events will occur. We have to have systems in place that can predict to the best of our ability when these events will occur and then put in place measures to control the events and any future events. This is what high-reliability organizations do – day in and day out. It is not easy.

The ultimate goal of the quality improvement process, conceptually, is to implement interventions to make iterative improvements to a process or system and sustain change. The process begins by identifying a process or system that may be inefficient, and hence we begin to identify existing problems. Hospital executives, leaders, frontline staff, and patients and families can all help to identify inefficient quality and safety processes. Identifying the problem involves recognizing mistakes and identifying when there are too many steps in the process or when a process is too complicated; ultimately, a process or system that does not produce reliable results is amenable to a quality improvement intervention. Not all problems are amenable to an improvement initiative. Categories of potential projects usually address one or more of the following: effectiveness, efficiency, patient satisfaction, safety, throughput, waste reduction, provider, and staff engagement.

The questions asked to identify the problem can differ depending on if you are attempting to fix or design your system or process. When looking to fix a current system or process, answering the following questions can help you identify the problem:

What worries you? What makes you believe there is an easier way to get the expected outcomes? Are we working hard and not smart? Are we failing to meet practice standards? Have we defined the standard work?

When you are seeking to design a new system or process, answering the following questions can help you identify the problem: Is there an opportunity to utilize work that we are already doing? In what areas are we not the best, in comparison to similar institutions? What can we do better?

Additional questions to consider when identifying the actual problem include the following: What were your thoughts at the time you decided this was a problem? Why is this a problem? How does this problem affect the quality of patient care? Does this problem affect efficiency, effectiveness, equity, timeliness of care, family centeredness, or safety of care provided? These are the six domains of healthcare quality as defined by the Institute for Healthcare of Improvement . Placing the potential improvement initiative into one of the six domains of healthcare quality further confirms the need to address the problem and helps the management and the board to understand the prioritization of the initiative. This information also can assist in scoping or identifying the specificity of the problem. Indeed, chapters in this book will demonstrate how, ultimately, a data-driven approach will identify opportunities for improvement and assist in measuring improvement.

What is most important is that projects are aligned with organizational goals and priorities. Aligning improvement projects with organizational goals ensures hospital leadership support, minimizes roadblocks, and improves the accessibility to available resources.

Before starting a project, determining if the organization or clinical area is ready to embark on such a project can help determine success and is a compulsory assessment. When organizational or clinical area readiness is high, organizational members are more likely to initiate change, exert significant effort, exhibit greater persistence, and display cooperative behavior [2]. Members of the organization/unit must be committed to the change by having a shared desire to implement a change and also believe that capacity for the change to occur exists. The ability to implement change is directly related to the organizational/unit member’s perception of three key determinants: task demands, resource availability, and situational factors [2].

Specifying metrics is necessary to make the problem measurable and explains what is needed to make actual improvements. A popular quote by Dr. Donald Berwick, founder of the Institute for Healthcare Improvement and past CMS Administrator, is [S]ome is not a number. Soon is not a time. Indeed, the specificity requisite in a quality improvement project will ensure proper processes are developed to drive the desired change with outcomes expected to follow.

We discuss various models for improvement and strategies to embark on improvement initiatives in this book, with the goal for the reader to understand potential techniques or methodologies that can be employed to drive and sustain change. At Children’s National, we employ the Institute for Healthcare Model for Improvement , which utilizes aim statements and key driver diagrams to identify, prioritize, and be the levers of change. There are many sources of deep knowledge on these techniques, and the goal of this book is to provide the reader with a general awareness that these principles exist and how they should be utilized in your healthcare setting to drive improvement. This textbook is not meant to be a thorough or exhaustive tome on these important topics.

Ultimately, a project will need a robust aim statement, which should include data and numeric goals that can be reliably measured. A common mnemonic is to develop a SMART aim : one that is Specific, Measurable, Applicable, Realistic, and Timely. The aim statement must include what the project will increase or decrease, the group or population the project will affect, the baseline (from what) and goal (to what), and a timeframe (accomplish by when and sustain for how long).

The SMART aim should be linked to a global aim. In other words, SMART aims should be part of larger organizational goals rather than be siloed to be most impactful. We provide an example of a blank key driver diagram (Fig. 1.1) that is used at Children’s National Hospital. The template facilitates a shared, common understanding and alignment throughout the organization and provides instant recognition for management, leadership, and the board to instantly understand a quality improvement initiative. It is imperative to maintain that the global aim is the larger picture – what we are trying to improve.

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Fig. 1.1

Key driver diagram template used at Children’s National Hospital

With a SMART aim and a global aim, we have to ask what are the levers that will result in improvement. These are called drivers, and the primary drivers are often referred to as key drivers. Ultimately, the key driver diagram (Fig. 1.1) is the road map to help achieve a shared understanding of what we are trying to achieve and how we are going to get to the specific goal. A key driver diagram is not static. As conditions change, drivers are accomplished, and milestones are achieved, it is necessary to update the project key driver diagram. Management and the board can assist the organization by framing questions and guiding decisions and tactics based off the key driver diagram.

Once we have identified a problem that is amenable to an improvement methodology, and we have created a SMART aim with the KDD (key driver diagram ), then we can begin the hard work. This book details cycles for improvement, which are called PDSA cycles and are iterative, narrowly scoped, improvement initiatives. As we progress through several PDSA cycles , conducted in serial and parallel fashion, we must monitor performance. There is a primer on data in this book that barely touches the level of sophistication of data that healthcare organizations use to measure and describe the data associated with improvement. We employ at least a dozen of individuals committed to using data to drive improvement! The data helps tell the story, but also to monitor performance. Without robust data processes, and an understanding of data, improvement will not be attained as it becomes impossible to know where a project is in its lifecycle without being able to accurately measure it; data is the ruler.

We will eventually determine successful PDSA cycles and drivers which are successful in advancing the aim; then, the QI project moves to the stage of spread. Spread involves taking the initiative and project from a micro-system (one unit in the organization, one division, one management span of control, one group of employees, etc.) to a larger part of the organization/enterprise. For example, an initiative that was successful in a specific unit (e.g., 4-Main) then needs to be spread, as pertinent, to the other inpatient units, to possibly outpatient areas, and if applicable to other hospitals/care delivery sites in your organization. The spread of an improvement initiative can happen quickly or over a longer period of time, depending on the process that needs to be in place to support the change. Management and the board can provide tremendous assistance in the important decision and guidance as to when to spread successful initiatives.

The final stage of a QI initiative is the sustainment of gains. This is probably the most difficult part of the project. When does a project no longer require day-to-day management and oversight and when can we trust that the structure and processes that we have put into place will be able to be sustained as a permanent change to the processes? This is a very difficult decision, as prematurely putting a project into sustain mode or delaying too long to put a project into sustain mode comes at an opportunity cost. Resources and time are finite; if a project is ready to be sustained, then doing so supports reallocation of efforts to new initiatives or those that need additional support. However, prematurely sustaining a project can be more harmful than the initiative itself. Your hospital’s chief quality and safety leader, chief medical or nursing officer, or other leaders and managers can help best assist with framing this discussion and assisting with this determination driven by deference to expertise.

The easy part of this work is getting started. This book is intended to remove the intimidation factor of quality, safety, quality improvement, and change. As a primer, we hope that readers will be able to quickly understand key concepts that will provide a ladder for each reader to climb in their journey of quality improvement sophistication. At the conclusion of reading this book, the reader will have the tools to engage in meaningful discussions with patients, colleagues, management, and the board on various facets of quality improvement. It is this easy.

References

1.

Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco: Jossey-Bass; 2011.

2.

Bryan J, Weiner A. Theory of organizational readiness for change. Implement Sci. 2009;4:67.Crossref

© Springer Nature Switzerland AG 2021

R. Roberts-Turner, R. K. Shah (eds.)Pocket Guide to Quality Improvement in Healthcare https://doi.org/10.1007/978-3-030-70780-4_2

2. Model for Improvements

Katherine M. Worten¹  

(1)

Quality, Safety, and Analytics, Children’s National Hospital, Washington, DC, USA

Keywords

Improvement scienceQuality improvementModel for improvementLeanSix SigmaPerformance improvement

Improvement Science

Every successful project starts with a plan. Whether it be a house project to build and design the perfect outdoor space, a history project for school, or a business project for work, those that are well defined from beginning to end have a higher rate of success. While hard work is most certainly a contributor, the real driver is the method or planning applied to tackle the issues at hand.

Taking a systematic approach to addressing a problem in order to achieve desired outcomes is not just a strategy, but a scientific method.

The science of improvement, as defined by the Institute for Healthcare Improvement (IHI) , is an applied science that emphasizes innovation, rapid-cycle testing…and spread in order to generate learning about what changes… produce improvements [1].

Improvement science is not a new concept and has been around for a while with organizations like Toyota and Bell Labs [2]. The gurus of quality improvement (QI), Walter Shewhart, W. Edwards Deming, and Joseph Juran, simplified and refined the science of improvement. While studying the method these leaders used to improve the process for building better cars or improving information technology and communication, the question became whether or not this same philosophy and attitude could be translated to other industries. Luckily for health care, the answer was a resounding yes!

The Associates of Process Improvement (API) defines the science of improvement and further explains that the proper application of this science requires the integration of improvement methods, tools, and subject matter experts to develop, test, implement, and spread changes [3]. In health care, there are a variety of approaches or models used to foster improvement, efficiency, and effectiveness of a system or a process. A couple of models used in health care QI are the Model for Improvement (MFI) and lean/Six Sigma. While it’s important to choose a reliable model to guide your work efforts, it is more important that you trust the process and fully commit to using the QI tools and processes.

Model for Improvement

The Model for Improvement (Fig. 2.1), developed by API, has been successfully used in hundreds of health care organizations across the globe [3] to improve diverse processes and outcomes. The model has two parts: answering three fundamental questions and conducting tests of change. By answering the three fundamental questions, you have established your plan of action. The questions that are required to be answered by collaborative teams are the following: (1) What are we trying to accomplish? (2) How will we know that a change is an improvement? (3) What change can we make that will result in improvement? The second part to the Model for Improvement is implementing and testing change through what is called the Plan-Do-Study-Act (PDSA) cycle (Fig. 2.2).

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Fig. 2.1

The Model for Improvement

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Fig. 2.2

Plan-Do-Study-Act (PDSA) cycle

Question one, What are we trying to accomplish?, speaks to the end goal or aim. In other words, why are we here? This might seem like an easy question, but to do this right, there must be a level of specificity provided to the answer, including the population that will be affected and the time frame which one would wish to achieve their accomplishment. By providing specific details, you have delivered clear and specific intent among your team. Everyone will be on the same page and have a clear understanding of the goal and hold each other accountable for getting the job done.

Question two is, how will we know that a change is an improvement? or "what does good look like? Teams should use quantitative measures and data to identify measures that track their success. Where is the finish line? Once a team reaches that measure, this is the point at which you might trigger the we did it!" celebrations. An important thing to consider is a realistic target or goal that is deemed successful. Will you be able to eliminate patient wait time in a clinic schedule by 90% in 6 months’ time? Probably not, and that’s okay! Setting realistic goals will help your team visualize the finish line and have it within reach. The emphasis is on incremental change and incremental improvement. You can shoot for a 20% improvement over 6 months and maybe another 15% improvement another 6 months after that.

Question three asks, what change can we make that will result in improvement? This is when innovation, creativity, and sometimes common sense come into play. The team, who should consist of those who are closest to the work, generates ideas and solutions they think will positively impact change. It is important to know there is not one right answer. There is no silver bullet that will solve the entirety of a problem identified in a system or process. Teams should select a number of changes they think will bring them closer to success.

It might be easy to simply identify the aim/goal, determine quantitative measures for success, and come up with solutions that we believe would lead to improvement. But then what? The key ideas and solutions developed are then implemented in a cyclical fashion, which leads us to the second critical component that makes up the Model for Improvement. The concept of the Plan-Do-Study-Act (PDSA) cycle is to test out changes to see if they are helping or hurting. To put this into perspective, you wouldn’t buy a car fresh off the conveyor belt without having the breaks, airbags, and steering tested. Automakers use a series of tests to make sure their final product will satisfy their customers, both in comfort and safety and reliability. The idea behind testing a car is that it allows manufacturers to work out the kinks. Potential problems that negatively impact the product can be corrected or modified slightly before the car goes into full production or rolls onto a dealership lot. If you think about it from a cost perspective, it is a lot cheaper to eliminate a problem before production, rather than having to find and fix the problems after the fact.

The PDSA cycle asks that teams take their solutions (the plan), try it (do), observe the results (study), and then do something with that plan based on what you learn (act). If you have favorable results, you can adopt the intervention. If the test of change sort of worked, you can adapt the idea or tweak it a little and try again. And if you have failed miserably, it’s okay to abandon the idea altogether. The PDSA cycle allows for a threshold of failure. It is at such a small scale that the idea of failing, learning from the failure, and trying again is part of the process.

Rather than trying to boil the ocean and solve world peace in one fell swoop, teams are encouraged to make incremental, small-scale improvements. The idea is to start small with hunches, theories, and ideas and discover what works and what doesn’t work. From there, iterative changes and refinements are made with each cycle until you find the sweet spot that results in improvement. This will organically create a ramp of multiple PDSA cycles of improvements shown in Fig. 2.3.

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Fig. 2.3

Multiple PDSA cycles

Let’s take a real-world example to demonstrate how to apply the Model for Improvement in the scenario of moving to a new city or even a different part of town. Typically a new move requires a bit of time to become acclimated with your surroundings. For me, it starts with finding the nearest essentials: grocery stores (fingers crossed for a Trader Joe’s), pharmacy, coffee shops, and of course, Target. In addition, I need to make sure I know how to get to and from work the most efficient and safest way possible. My goal or aim was to get to work no later than 7:30 am Monday to Friday each week while maximizing sleep. I started timing myself each day to gather data about how long it was taking me to get to work in the morning. Without knowing this information, it would be impossible for me to set a goal or to know what good, better, and best might look like. After 1 month, or 20 days, I had an average time of arrival of 14 minutes, the quickest time was 11 minutes from A to B, and the longest time was 18 minutes. Going back to our Model for Improvement, the goal or aim was set, the measures of success were defined by the data I had collected, and now, I got to explore ideas and decide what changes I could try to achieve my results. The first thing I did was to consult the experts to the process who could have already found solutions to the very problem I was trying to solve. More often than not, you can assume that someone at some point in time has attempted to address the very problem you are trying to tackle. In that case, there is no need to recreate the wheel, but learn what successes and failures they experienced. I could find someone that lived nearby and traveled to the same location and ask what route they take and why. I could also do a little research and see what Google Maps had to offer. I found there were three routes to get me from point A to B, two taking the highway and one taking back roads. Based on the information gathered, I would start my first PDSA cycle: the route. I decided to take the highway with the shortest estimated time of arrival, according to Google Maps, a new way from the baseline data I had gathered. After testing that out for a couple of days, I learned that it took me closer to 15 minutes to my destination. I decided to tweak my plan just slightly by taking the same route, but leaving 5 minutes earlier; this would be my second PDSA cycle. I made my plan, left 5 minutes earlier the next couple of